Download Common Toxicological Errors: What*s the problem

Common Toxicological Errors:
What’s the problem here?
Russell Berger, MD
Co-Director of Medical Toxicology
Cambridge Health Alliance
Instructor in Medicine
Harvard Medical School
Background
• This WILL be interactive.
• You are going to have to figure out what you want
to do.
• Introduce yourself first time through and read the
prompt out loud.
• If you don’t know the answer, you can pass once
to your colleague.
• 27 M heroin user is found in Starbucks
bathroom with agonal respirations. EMS gives
the patient 2mg narcan enroute to your ER.
Patient is shaky and diaphoretic on arrival. He
demands to be discharged. Your charge nurse
wants him out of the ER.
• What is the problem here?
A 7 month old child mouths a 8mg suboxone
tablet. He is brought to the ER by the babysitter.
He is stable with a normal sat, respiratory rate,
blood pressure, etc. The medical resident tells
you she wants to send the patient home.
• A 24 female with bipolar disorder presents
with ataxia. Lithium level is 2.0. She is 7 hours
past her ingestion time. Renal says just give
the patient normal saline and we’ll see the
patient tomorrow in consultation.
• A 16 year old boy presents after taking a
bottle of Aspirin. He has nausea and vomiting.
Asa level is 14 mg/dl(nl < 10). Patient is
medically cleared for psych.
• An aspirin overdose presents in clear
respiratory distress. Your intern who has just
finished their anesthesiology rotation wants to
intubate the patient?
• A 44 type 2 diabetic overdoses on his
glyburide. You give him d50 when his sugar
returns at 46. When his sugar drops again,
you give him another amp of d50 and place
him on a d50 drip
• A 56 year old fire victim presents to your ER
with singed nares. You intubate the patient
and check labs. Carboxyhemoglobin level is
18%. Labs demonstrate lactate of 12. You
give the complete lilly kit.
• A 78 F is brought to your ER with N/V and
symptomatic bradycardia. You look at her
med list and realize that she is on digoxin. You
see that her level is 4.0 and she weighs 80 kg.
Therefore, you give her 4 vials of digibind. You
get a call from the medical resident scolding
you for sending up an unstable patient to the
floor with a dig level that now is 6.0.
• An 8 year old child is dared to eat a box of rat
poison. You admit the child to the hospital
after you learn that he has eaten several
pellets.
• A 30M presents with chest pain. EKG
demonstrates ST elevations. You suspect
cocaine chest pain. Cardiology refuses to cath
the patient.
• A 39 M is in recovery from substance abuse
and is prescribed methadone. He develops
nausea and vomiting in the ER because he
missed his morning dose of methadone. You
give him zofran.
• A 1 year old child presents to the ER after
eating paint chips. The child is asymptomatic
so is therefore discharged.
• A 24M presents following a TCA overdose with
a QRS complex of 129. He is placed on a
bicarb drip with narrowing of the complex to
108. Patient remains tachycardic and is
admitted to the ICU. On arrival, citing the
normalizing QRS complex, the bicarb drip is
shut off.
• A 14F presents after ingesting her
grandmother’s venlafaxine. Patient is
tachycardic and hypertensive. You give her
activated charcoal and admit her to the PICU.
• A 44M alcoholic presents with apparent
intoxication. He has no evidence of trauma
but he is new to your department so you
decide to scan him? CT reveal basal ganglia
hemorrhage. ETOH level results at 265. You
admit the patient to the neurosurgical icu.
• A 22 year old South East Asian man presents
with seizures. On arrival, he is still seizing.
Therefore, you give
2 ativan-no effect
2 ativan-no effect
Load with phenytoin-no effect
Intubate with propofol-Still with EEG based
seizures
• A 28M, presents with chest pain. Heart is
racing at 165. Intern suggests beta blockade
to help lower the HR.
• A 19F presents with TCA overdose. QRS is
150ms. Patient is on bicarb drip and, to this
point, has not seized. Serum pH is 7.6.
Attending states that it is critical to keep the
bicarb going.
An 8 year old male presents with hypotension
and bradycardia. His fingerstick is 34 on arrival.
Your attending physician tells you the patient’s
clinical presentation is completely consistent
with a calcium channel blocker overdose.
• A 24M presents following an amlodipine
ingestion. You assess him, find him to have
warm extremities, borderline tachycardia, and
an entirely reassuring physical exam. You
decide that you can safely discharge him.
A 28F presents with an intentional overdose of
30 days worth of her 300 mg INH tablets. The
patient is intubated, started on a versed drip,
and given 3g of pyridoxine.
• A 15F presents with nausea and vomiting
following a deliberate tylenol ingestion. She is
started on the NAC protocol. She gets
150mg/kg over the first hour, then
100mg/kg/hr for the next four hours, then
50mg/kg/hr for the remainder of the 16
hours.
• A 22 year old college senior presents with
hypertension, tachycardia, runs of v-tach, and
extreme agitation. She is experiencing
profound nausea and vomiting. Measured
potassium results at 3.0. The medicine team
wants you to replace the potassium
aggressively before the patient comes to the
ICU.
• A 6 year old presents after drinking kerosene
accidentally. On arrival, his respiratory rate is
slightly accelerated. After a brief period of
observation and decontamination, he is
discharged home
• 64 F, presents with nausea, vomiting, and
altered mental status. Ca 7.5. Lactate is 4.0.
Creatinine is 1.8(patient’s baseline is 0.8). pH
is 7.18. You give vanc and zosyn and admit to
the ICU.
• A rich, elderly, woman complains of nausea
and vomiting. She notes that she has severe
leg pain and believes that she is losing her
hair. Thinking that she is FOS, you refer her to
psych.
• A 86M presents with a large stroke. Because
of the stroke, neurology tells you the patient is
at risk for seizure, increased metabolic
demand, and subsequent death. Therefore,
they tell you to push dilantin.
A Brazilian woman presents with a dig level of
10. Despite this, she is asymptomatic. At the
urging of your attending, you give the patient
digibind.
The End